Years ago, when Angraini Sari Astuti was diagnosed with ovarian cancer, she experienced first-hand how difficult it can be for Indonesian adolescent girls to visit a qualified health professional when they desperately need one. Not because there were no doctors where Angraini lived, near Solo in Central Java, but because of the stigma associated with anything related to premarital sex in the world's most populous Muslim-majority nation.
“In 2008, when I checked into [the office of] a gynecologist in preparation of my tumor surgery, other patients stared at me,” now-25-year-old Angraini said at a youth event on the sidelines of the International Conference on Family Planning held in Nusa Dua, Bali, late last month. “They were wondering: why would such a young girl come to a gynecologist?”
Angraini, who fully recovered, is now an energetic and outspoken youth activist working with the United Nations as a volunteer to call on the Indonesian government to give youngsters a seat at the table when policies are made that directly affect them.
Activists like her say empowerment and education are more necessary now than ever before, because while the country's family planning program has been widely hailed as a great developing-world success story, the numbers on adolescent sexual and reproductive health in Indonesia remain disheartening.
65 million young people
Indonesia's successful family planning program, which lowered the country's total fertility rate from 5.6 in 1967 to 2.6 in recent years, has cleared the way for a much-anticipated demographic dividend.
There are over 65 million people in Indonesia today aged between 10 and 24: almost 30 percent of the population. But even as this may be good news in terms of economic growth potential, illegal abortions abound and HIV transmission rates are on the rise, while the government is not legally allowed to provide any means of contraception to people who are not married. Regular health clinics tell youngsters that abstinence until marriage is the only way to stay out of trouble.
According to data from the United Nations Population Fund (UNFPA), people between the ages of 20 and 29 account for almost 40 percent of newly confirmed cases of AIDS in Indonesia. These numbers suggest that many get infected with HIV between the ages of 15 and 24.
UNFPA also notes that more than half of reported HIV cases in the country are due to unprotected sexual intercourse, with intravenous drug abuse being another major cause.
Maternal mortality
Reliable numbers are hard to come by, but experts estimate there are at least two million abortions per year in Indonesia. The fact that these abortions mostly involve married women in Indonesia indicates that access to contraception is hardly something that only affects adolescent girls.
As abortion is illegal in Indonesia except in cases of rape, foetal abnormality or when the pregnancy threatens the mother's life, most of these procedures are carried out unsafely. Indonesian girls and women with an unwanted pregnancy ingest menstruation-inducing herbs, are given a uterine massage or even have foreign objects inserted into their uterus.
Indonesia's maternal mortality ratio (MMR), or the number of maternal deaths per 100,000 live births, remains high, at an estimated 126, and unsafe abortions cause an estimated 16 percent of these deaths.
In other words: some 6,400 women died from pregnancy-related causes throughout the archipelago last year, and over 1,000 of these women died because of an unsafe abortion.
Even though Southeast Asia's largest economy is performing better than countries like Laos (197) and Cambodia (161) in terms of MMR, it still lags far behind neighbors such as Vietnam (54), Malaysia (40), Thailand (20) and Singapore (10).
Child marriage
One of the ways Indonesian authorities are trying to prevent unwanted pregnancies and stem the rise of sexually transmitted infections such as HIV/AIDS, is by promoting abstinence until marriage, for instance by limiting the availability of contraceptives for unmarried people.
However, one of the consequences of this policy – which is generally accepted by people across the country because it is considered to be in line with religious teachings and tradition – is that many people marry young.
In many parts of Indonesia, unmarried girls are being labeled perawan tua, or “old virgin,” as early as in their late teens and child marriage remains very common, despite the many dangers associated with the practice.
Humairah Samad, a senior high school student from Makassar, in South Sulawesi, confirmed that where she lives, too, many tie the knot at a young age.
“Our culture has been like that for generations,” she told the Jakarta Globe at the family planning conference in Bali, citing the need for better education on issues of sexual and reproductive health to break that tradition.
Another Indonesian youth activist, Nanda Fitri Wardani, a young MD from Lampung who studied at Bandung's Padjadjaran University, says many girls in Indonesia have plenty of dreams but are often not empowered by their parents and sometimes end up getting married as early as age 13.
Such a young marriage usually means the end of school and any prospect of a career beyond motherhood.
Harm reduction
Nanda says she believes the Indonesian government should be supported in its decision to not provide contraceptives to unmarried people, citing the state ideology of Pancasila and its first principle: belief in God.
“Having sexual intercourse before marriage is forbidden based on the religions that we follow here,” Nanda said in Bali, stressing that abstinence remains the best way to stop the spread of HIV/AIDS among young people.
Siswanto Agus Wilopo, a professor of reproductive health at Gadjah Mada University (UGM)'s faculty of medicine, however, says the government needs to approach the issue differently.
Siswanto told the Globe he was quite confident that the legal situation would not change anytime soon, as a majority of legislators in the House of Representatives believes that the law can prevent unmarried people from engaging in sexual intercourse.
Faced with such unfavorable odds, the professor says the country needs a harm reduction policy, because the numbers suggest there clearly is a problem, regardless of what politicians say. A start would be the provision of contraceptives to unmarried couples, as part of an emergency regulation, he said.
“You have to go step by step,” said Siswanto.
“One kind of harm reduction policy is the availability of ECP [emergency contraception pills] which will prevent unprotected sex ending in abortion. It is better to use a pill compared to having an abortion, isn't it?”
“We start with that, campaign about it. If you present the facts, if you present the data – people in Indonesia are smart … I believe that at least harm reduction can be promoted.”
For now, however, the Indonesian government is adopting a hands-off approach. Although some believe the sale of such prophylactics needs to be limited to prevent people from engaging in premarital sex, condoms are still available in supermarkets and convenience stores in major urban areas.
Youth-friendly services
UNFPA in 2014 launched an initiative in cooperation with the private sector that is aimed specifically at helping adolescents. As part of the Unala program, which is being piloted in Yogyakarta, affiliated clinics specialize in providing youth-friendly physical and mental health services.
At the Unala clinics, selected GPs offer health services for youngsters who might be afraid of the social stigma attached to extramarital sexual activity, real or perceived. One way of doing this, for instance, is by using an appointment-only system – which is very unusual in the Indonesian health sector – to avoid prying eyes in the waiting room.
Besides Unala, there are other initiatives to help people in need, such as a hotline run by Yogyakarta-based activists that allows girls and women with an unwanted pregnancy to discuss – free of charge and judgment – what options are available.
Such sessions are aimed at preventing tragic but all-too-common situations where girls or women end up having unsafe abortions at one of the many illegal clinics in Jakarta or at the hands of a local midwife.
Meaningful participation
Babatunde Osotimehin, the executive director of UNFPA, says youngsters all over the world should be given the space to express themselves, so that governments and NGOs understand what they want, and what they need.
And one of the most important things that young people need, is comprehensive sexuality education (CSE), he says, stressing that this in fact is the right of every young person.
In Indonesia, only few schools offer such programs, however. Some others do teach children about sexuality, but take a fear-based approach instead of one that stresses a young person's rights.
Apart from CSE, another important step is greater involvement of men, the UN under-secretary-general said, speaking at the family planning conference in Bali.
“There is no man in this world who would like to see his daughter die,” said Babatunde, “or see his wife die.”
Angraini, the Indonesian youth activist, told the Globe that for family planning and sexual and reproductive health programs to work, meaningful participation of young people at all levels of the policy-making process is essential.
“Listen to the young people themselves,” she said. “Don't just ask them to attend a seminar when everything is already settled.”
Apart from empowerment, there is a clear need for adequate, youth-friendly health services across the country, she said, to clear all hurdles for young people “concerned about confidentiality and judgmental opinions from others.”
“Involving young people, both married and unmarried, in family planning education, and raising their awareness on this issue, will have a positive impact in lowering maternal and child mortality and morbidity,” Angraini said, “as well as equip young people with the information they need to make their own decisions.”
But she stressed that young Indonesians should not just remain passive while waiting for change to happen.
“Let us … work together with parents, families, government health personnel, teachers [and] educational institutions … [so that they all] fully recognize young people's need for non-judgmental understanding, the right information, adequate health services and comprehensive sexuality education,” Angraini said.
“We are the future of family planning.”
This article was originally published in the Jakarta Globe.
Tags: family planning
